Case Study: Intermittent Squeezing Chest Pain in a 49-Year-Old Male – Evaluation of Possible Stable Angina
Case Study: Intermittent Squeezing Chest Pain in a 49-Year-Old Male – Evaluation of Possible Stable Angina”
Onset 2.5 hours ago
Location deepin chest, pierces through back
Duration
Characteristics worsens with deep inspiration
Aggravating worsens when laying down, moving, and breathing
Relieving eased pain when leaning forward
Timing /
Treatments
Severity 8/10
History of Present Illness
Category Data entered by AA
Reason for Encounter Chest pain
History of present illness A 57-year-old female 10 days status post inferolateral STEMI with stent placement, presents to the ED with a 2.5-hour history of progressively worsening chest pain. The pain is sharp and stabbing, gets to pierce through her back with inspiration. Pain is partially relieved by sitting up and leaning forward.
She reports mild nausea without vomiting, denies fever/chills, palpitations, lightheadedness/syncope, SOB, cough, URI, or extremity/catheterization site pain or swelling. She reports compliance with her antiplatelet medications (ASA and clopidogrel), pantoprazole, and aspirin since discharge. On exam, patient is febrile, shallow respirations at normal rate, low-normal oxygen saturation, and has pericardial friction rub. PMH is significant for hypertension, hyperlipidemia, tobacco abuse, obesity, and type-2 family history of heart attack and diabetes.
Past Medical History
Category Data entered by AA
Past Medical History Hypertension Hyperlipidemia
Hospitalizations / Surgeries Acute inferolateral wall ST-elevation myocardial infarctionwith
PCI/stenting of the right coronary artery (RCA).
Balloon angioplasty of the left circumflex artery.
Medications
Category Data entered by AA
Medications Clopidogrel 75 mg QD
Atorvastatin 80 mg QD at bedtime
Pantoprazole 40 mg QD
Aspirin 81 mg QD
Allergies
Category Data entered by AA
Allergies Bactrim (rash)
Preventive Health
Category Data
entered by AA
Preventive health Up to date immunization including flu
annually. Reports gynecology normal.
Family History
Category Data entered by AA
Family History Father - Heart attack, 59 years old
Mother - Type 2 Diabetes
Sister - Type 2 Diabetes
Social History
Category Data entered by AA
Social History Freelanceworker, telephone sales. Smoked a pack and a
half for the past 25 years. Quitted since she’d
the heart attack and takes a healthy heart diet.
Review of Systems
Category Data entered by AA
General Slightly fatigued. Laying still to avoid movement, breathingslowly.
Integumentary / Breast Warm skin; no significant diaphoresis.
HEENT / Neck Denies any problems with headaches, double vision, difficulty with
night vision, hearing problems, ear pain, sinus
problems, chronic sore throats, or difficulty swallowing.
Cardiovascular Chest pain. Heart attack 10 days ago.
Denies history of irregular heartbeats nor palpitatio
Hypertension
Hyperlipidemia
Respiratory Denies wheezing and sputum production.
Gastrointestinal Reports mild nausea and reflux.
Genitourinary Denies urinary frequency, pain, incontinence, or difficulty.
Musculoskeletal Denies chest injury. No problems with muscles and joints.
Allergic / Immunologic
Endocrine Denies problems with heat or cold intolerance, increasedthirst,
increasedsweating, frequent urination,or change in appetite.
Hematologic / Lymphatic No reports of bruising, bleeding gums,
sites of increased bleeding.
nose bleeds, or other
Neurologic Denies dizziness, seizures, numbness, or weakness.
Psychiatric Reports nervousness due to chest pain.
Physical Exams
Category
Data entered by AA
General Obese with a BMI of
AOx4
Skin and febrile. is dry 29.4.
Skin Skin warm and dry with no lesions.
Nails without ridging, pitting, or
Capillary refill < 2 sec.
Quincke’sTest: Blanchingobserved.
peeling.
The Patient is Alert on AVPU Score.
The pupils are rounded, central, responsive to light & equal on both sides. Exposure: No
apparent injuries in body .
General Examination
Patient is alert , conscious , oriented to time , place and persons , average built , quiet facial
expression , no special decubitus , average intelligence ,he's cooperative
Cardiac Examination By inspection:
There is no skin redness, pigmentation, ulceration, fistulae or scars.
Respiration is abdomenothoracic.
No visible pulsation at the apex of the heart.
By Palpation:
Palpable pulsation of the heart at the fifth intercostal space in the midclavicular line.
There are no masses, swellings, tenderness or pulsating masses.
By Auscultation:
No abnormal cardiac sounds, muffling or murmurs were heard at the apex of the heart,
xiphisternal area and aortic areas.
Differential Diagnosis
1. Acute Coronary Syndrome (most probable)
2. Pericarditis excluded by absence of localized friction rub over pericardium.
3. Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.
4. Musculoskeletal Pain excluded by not being aggravated by chest movement and not being
relieved by changing posture.
5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of
cough, haemoptysis, friction rub on the chest and audible abnormal breathing sounds.
6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia,
hematemesis or heartburn.
Provisional Diagnosis